The Battle of the DSM-V

There are few areas of medicine filled with more controversy than psychiatry. Compared to heart disease or a viral infection, mental illness is far more difficult to diagnose, with symptoms that are often vague, subjective, or difficult to accurately measure. To try and bring order and reliability to the assessment and treatment of mental illness, the American Psychiatric Association has published The Diagnostic and Statistical Manual of Mental Disorders since 1952. The DSM, as it’s known for short, is a guidebook for psychiatrists, psychologists, mental health researchers and insurance companies, a framework by which to define the amorphous world of mental health for treatment, research and coverage.

Of course, our knowledge and perception of mental health and illness has changed somewhat over the past 60 years. The DSM has changed as well, undergoing several revisions – the current version is the awkwardly named DSM-IV-TR, a sort of intermediate revision that was published in 2000. Virtually since that time, psychiatrists have been working on the fifth total revision of the DSM, an exhaustive process that yielded the “draft” version of the DSM-V published online earlier this month.

Now, the real fun begins. For the next two months, public comments will be accepted on the draft DSM-V, allowing all parties who craft and use the manual to fight it out over several controversial changes before they are officially codified. Because of the competing interests involved in the creation of the DSM, this process can lead to psychiatric pyrotechnics.

“It’s a little bit like watching a circus,” said Scott Hunter, director of pediatric neuropsychology at the University of Chicago Medical Center. “Ultimately, it’s as much political and cultural as it is scientific. That’s why I’m both encouraged in some ways, and amused in others.”

Hunter has a particular interest in the revisions. As controversial as adult mental illness may be, pediatric mental illness turns the discussion’s temperature up even higher – as Exhibit A, just look at the debate that perpetually rages around autism. Sure enough, the strongest disagreements and the bulk of the media attention surrounding the DSM-V draft have to do with the mental health of children, and autism is sitting shotgun.

“Scientifically, Asperger has not been well-differentiated from high-functioning autism,” Hunter said. “There’s very little that’s different in terms of the core difficulties and the likely neurobiological underpinnings. So I scientifically can think about Asperger as a component of the autism spectrum, and I will teach parents that that’s what the disorder is, but they’re going to latch onto a label that’s comfortable. That’s where we’re going to get into some interesting discussions, and for some individuals, I think it’s going to be very tough to make that transition. If you come to understand who you are based upon a particular classification and you have that removed, what are you left with? A shake-up.”

A similar re-drawing of the boundaries has been proposed for ADHD, where the current subtypes of hyperactive-impulsive, inattentive, and combined may be reunified into a single diagnosis of ADHD. While these subtypes may look very different clinically – think a child who can’t keep still vs. a child who is merely unable to focus for extended periods of time – there’s little difference in terms of how they are treated, Hunter said. But he also said combining them all into a single diagnosis may disrupt research and blur important nuances from individual cases.

“Clinically, I see representations of these subtypes, and they’ve been helpful to a degree. Are they truly reflective of what we ultimately classify the disorder as? Maybe not,” Hunter said. “But you lose some of the discriminability that can be helpful scientifically in looking at better understanding the genetics of the disorder and the etiology as well as looking at potential treatment outcomes.”

But not all unification efforts in the DSM-V are being met with resistance. Emil Coccaro, professor and chair of psychiatry at the Medical Center, specializes in an adult condition known as intermittent explosive disorder, or IED. A new disorder proposed for children in the DSM-V is called temper dysregulation disorder, which some psychiatrists hope will offer an alternative to the controversial diagnosis of bipolar disorder in kids. Coccaro, who acted as a consultant in the drafting of the DSM-V, said he and others who study IED see this new disorder as an opportunity to create greater continuity in their field. Rather than fight to protect their area of expertise, Coccaro said they are looking at ways to merge the two diagnoses in the DSM-V.

“What these kids probably have is what is called IED in adulthood,” Coccaro said. “Temper dysregulation disorder sounds better and there ought to be continuity from childhood to adolescence to adulthood, so we saw the wisdom of making it the same sort of thing, as long as the criteria sets are melded in a way that made sense to everybody.”

The name change may also place IED into a different chapter of the DSM, moving it from the vague “Impluse Control Disorders, Not Elsewhere Classified” to the well-thumbed section on “Mood Disorders.” Placing the disorder in a more “mainstream” chapter will earn it greater visibility among psychiatrists, Coccaro said, leading more people with the disorder to be diagnosed and treated properly.

But through all of the debates and arguments, he said, it’s important to remember that the DSM will always be in a constant state of revision and that the manual is meant to be a flexible tool.

“I think the process is probably as good as it can be, but it’s always going to be a compromise,” Coccaro said. “It’s not a bible, it’s a guide.”